Introduction

Chronic renal failure (CRF) is progressively perceived as a worldwide general

medical issue and key cause of poor prognosis. It is a serious disorder which

associated with a decreases in quality of life, increases of health care costs and

imposes a heavy economic burden on communities. Chronic renal failure refers to "an

irreversible loss of kidney function that can advanced to end-stage renal disease

(ESRD), it develops due to a multifactorial etiology over a period of a few years". In

this disorder the kidneys are not able to perform metabolic functions and cannot

maintain fluid & electrolyte balance (Dhudum & Bhore, 2020; Jancy & Parimala,

2020; Vaidya & Aeddula, 2020)

The precise incidence of CRF in children is unknown because its early stages

are asymptomatic. In the past two decades the incidence of CRF in children has

progressively increase, while globally the prevalence of CRF in children is reported to

be approximately 18.5-100 per million children. Adolescents have a mortality rate

that is 30 to 150 percent greater than the general population. An adolescent on dialysis

under the age of 14 years has only 20 years left to live, indicating the necessity for

specialist care. (Al Shahawy, El-Gamasy, Seleem, Mawlana & El Sharkaway,

2020; Raj, Patel & Ramachandran, 2017).

According to the statistical record of Mansoura University Children Hospital

340 children from age 2 to 18 years were undergoing maintenance dialysis during the

year 2018, this number increased to 360 in 2019 and this number increased to 397 in

2020 (Unpublished Statistical Records from Mansoura University Children

Hospital, 2018, 2019 and 2020). On the other hand, the statistical record of

Mansoura New General Hospital in the year 2018, reported that CRF of hospitalized

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children, who were under hemodialysis is 80, the number increased to 115 in 2019

and the number increased to 150 in 2020 (Unpublished Statistical Records from

Mansoura International Hospital, 2018, 2019 and 2020).

Hemodialysis (HD) is the treatment of choice which may be selected to

supplement the function of the kidneys and the most prevalent renal replacement

therapy for ESRF. Although it sustains the life of adolescents, it disrupts their normal

lifestyle. During HD sessions, the adolescents suffer from physical problems such as

hypotension, fatigue, nausea, vomiting, muscle cramps, and headache. Also, they

suffer from psychological problems such as stress, anxiety and depression, have a

significant impact on their daily lives. (Amini, Goudarzi, Masoudi, Ahmadi &

Momeni, 2016; Shahgholian, Jazi, Karimian &Valiani, 2016).

ESRF has a higher influence on adolescents, and it has a detrimental impact on

their growth and development, as well as contributing to family disintegration, social

isolation, and the possibility of mortality. As a result, it's critical to introduce new

ways to make care and adaption to HD treatment easier. Adolescents can respond well

to the instructions regarding their condition as dieting, fluid restriction, care of

vascular access and exercise techniques (Santana et al., 2020).

Adolescents undergoing HD often experience muscle cramps that is defined as

an involuntary muscle contraction that lasts for a long time. It is a painful and

unpleasant symptom that causes individuals to be uncomfortable, shortened dialysis

session, affecting sleep and health-related quality of life of those adolescents. It was

estimated that about 33% - 86 of children suffer from muscle cramps during HD

session which is a common reason for early termination of dialysis session.

Noncompliance with the prescribed HD treatment that results from recurrent muscle

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cramps during hemodialysis session, lead to fluid overload, hypertension and

cardiovascular disease (El-Deeb, Shadia, Montasser & Moursy, 2017).

The next most prevalent symptom of HD is fatigue that is defined as a

subjective feeling of weakness, loss of energy, exhaustion, and malaise. This disorder

lowers one's sense of well-being and has a variety of consequences on the physical,

emotional and cognitive aspects of adolescent life. Fatigue is a common symptom in

children with HD, with a prevalence rate ranging from 60% to 97 percent. Untreated

fatigue may lead to increased reliance on others, weakness, loss physical and

psychological comfort, which can lead to social isolation and depression (Shady &

Ali, 2019; Souza, Kummer, Cardoso & Lage, 2019).

The nurse acts as care provider and consultant during HD sessions and plays a

significant role in the management of immediate and long-term problems of the

adolescents with ESRD and their families. So nursing interventions are directed not

only toward preventing or managing complications of HD such as muscle cramps and

fatigue but also teaching adolescents about the non-pharmacological care. Non-

pharmacological methods are effective in relieving muscle cramps and fatigue level,

so the nurse has an important role in assisting adolescents under HD to identify

solutions that would help to alleviate and resolve these problems because

pharmacological treatments are costly, associated with adverse effects or other drug-

related problems (Aliasgharpour, Abbasi, Pedram Razi & Kazemnezhad, 2016;

Pagan & Pauly 2017).

Additionally, Bender (2017) clarified that the in health-care settings, the use

of complementary and alternative medicines (CAM) has expanded. In new

approaches, the nurse is viewed as a healer who plays an independent role in the

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patient's care. This approach gave rise to the phrase holistic nursing. Nurses can

improve their professional activities by incorporating complementary medicine. The

term "complementary and alternative medicine" refers to health-care procedures and

products that are employed mostly outside of the traditional health-care system,

reflexology massage is the most common CAM modalities.

Reflexology massage involves pressure and massage are applied to reflex spots

on the palm and/or foot. They act as a little mirror, reflecting all of the body's organs.

The mechanism of reflexology massage is unknown, however some hypotheses on

how it works include the gate control theory of pain, the nerve impulse theory,

increased endorphin release for pain control, improved lymph flow, immune system

stimulation, and blood circulation. Furthermore, enhanced blood flow aids in the

removal of toxins from the body. (Sharifi, Navidian, Jahantigh & Shamsoddini ,

2018).

As reflexology massage has become popular in nursing practice, and on top of

that, according to the literature review, no investigations on the effect of reflexology

massage on the symptoms reported by adolescents receiving hemodialysis have been

undertaken in Egypt. As a result, aims of this study is to evaluate the effect of

reflexology massage on muscle cramps and fatigue among adolescents undergoing

hemodialysis. Hopefully, this intervention will help to alleviate some of the negative

physical and psychological symptoms associated with renal failure and the various

therapeutic options available. (küçükkelepçe, & Karaca, 2017).

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 Significant of the study

A strong evidence points for many negative consequences of muscle cramps and

fatigue affect on the optimal health of adolescents undergoing HD and their quality of

life. These problems not only affect adolescents sense of wellbeing but also his/her

daily activities performance, relationships with family and friends and tolerance to

treatment. Reflexology massage has been extensively utilized in nursing specialties

which encompass orthopedics, neuroscience and palliative care. However, many

CAM modalities lack scientific evidence to support their efficacy and safety. While,

the outcomes of diverse research imply the useful and tremendous outcomes of

reflexology massage in many conditions such as fatigue, pain, migraine, constipation,

hypertension, renal disorders, digestive problem, chronic obstructive pulmonary

disease, muscle cramps and depression (Abd-Elmonem, Al-Tohamy, Galal, & Abd-

Elhalim, 2019; Timothy, & Robert, 2017).

Muscle cramps and fatigue are common among children undergoing HD that

occurs in about 35-80% of those children, and is important for the dialysis nurse to

become aware of these problems and provide appropriate care by using reflexology

massage for the management of these symptoms (Beladi, Zeraati, Moradi &

Mousavi, 2015; Hothi, Laskin, & Geary, 2016). For these reasons, there was an

urgent need to conduct this study for evaluating the effect of nursing intervention

using reflexology massage on muscle cramps and fatigue among adolescents

undergoing HD to reduce these symptoms and improve their quality of life.